Expecting the Best Improves CHD Survival

Action Points

Explain that patients with coronary heart disease who have positive expectations about recovery had greater long-term survival based on a study of nearly 3,000 patients undergoing coronary angiography.

Note that the cause for the association found is not known, and will need to be confirmed in other studies.

Patients with coronary heart disease who have positive expectations about recovery, expressing beliefs such as "I can still live a long and healthy life," had greater long-term survival, researchers reported.

Among a cohort of almost 3,000 patients undergoing coronary angiography, those with the highest expectations had adjusted hazard ratios of 0.76 (95% CI 0.71 to 0.82) for total mortality and 0.76 (95% CI 0.69 to 0.83) for cardiovascular mortality, according to John C. Barefoot, PhD, and colleagues from Duke University Medical Center.

"Patients differ widely in terms of their psychological reactions to major illnesses such as coronary heart disease," Barefoot's group explained online in the Archives of Internal Medicine.

To explore the specific potential influence of recovery expectations, rather than overall optimistic personality traits, the investigators enrolled 2,818 patients with clinically significant disease and followed them for about 15 years.

Recovery expectations were assessed on the Expectations for Coping Scale, in which patients agreed or disagreed with statements such as "I doubt that I will ever fully recover from my heart problems" and "My heart condition will have little or no effect on my ability to do work."

Patients were stratified into quartiles according to their expectation scores.

Hazard ratios initially were adjusted for potentially confounding medical variables, including age, sex, left ventricular ejection fraction, number of arteries with at least 75% occlusion, and the presence of other diseases, including congestive heart failure and cerebrovascular disease.

After further adjustment for psychosocial factors such as marital status, education, and belonging to a minority group, the hazard ratios were:

Total mortality, 0.83 (95% CI 0.76 to 0.91)

Cardiac mortality, 0.79 (95% CI 0.70 to 0.89)

Unadjusted mortality rates in the highest and lowest quartiles of expectation, respectively, were 28.8 deaths per 100 patients and 56.9 per 100 during the first 10 years, according to the investigators.

After adjustment for multiple variables, the mortality rates in the highest and lowest quartiles were 31.8 and 46.2 per 100, respectively, "illustrating a substantial magnitude of this effect even after taking multiple covariates into account," Barefoot and colleagues observed.

Functional status at one year in the cohort as a whole improved in 53.8% and declined in 35.2%, and multiple regression analyses found that expectation scores predicted functional status (P<0.001).

"These observations add to a compelling body of evidence that endorsing optimistic expectations for one's future heart health is associated with clinically important benefits to cardiovascular outcomes," Robert Gramling, MD, and Ronald Epstein, MD, of the University of Rochester in New York, wrote in a commentary accompanying the study.

"The degrees of evidence observed in these studies suggest that optimism is a powerful 'drug' that compares favorably with highly effective medical therapies," they wrote.

Other experts advised caution, however.

"Like all observational studies, unmeasured patient characteristics may have contributed to the better outcomes," observed Steven E. Nissen, MD, of the Cleveland Clinic.

"Patients with a 'positive' attitude may simply be healthier than patients with a negative attitude. In fact, their 'attitude' may reflect their health status," Nissen wrote to MedPage Today and ABC News in an e-mail.

Two "plausible" hypotheses can help explain the study findings, according to Barefoot and colleagues.

First, patients who are optimistic may use more effective strategies to cope with recovery from illness, by addressing the problem and reducing risk factors.

Second, patients whose outlook is more negative may experience worse stress that, in turn, could have harmful cardiac effects.

Limitations of the study, according to the investigators, included the possibility of confounders and selection bias.

"These findings argue for expanded efforts to understand the influence of recovery expectations and the potential benefits of attempts to modify them," Barefoot's group concluded.

However, the potential efficacy of such efforts is uncertain, according to James Kirkpatrick, MD, of the University of Pennsylvania in Philadelphia.

"Whether a patient's outlook can be changed (or patients can change their outlook) and improve results, and whether there are other factors which might make these patients do better, is unknown. One of those factors might be that cardiovascular providers give better care to patients with a positive outlook -- perhaps spending more time with them or being more conscientious," wrote Kirkpatrick in an e-mail to MedPage Today and ABC News.

"Future studies will need to take this possible mechanism into account," wrote Kirkpatrick.

This article was developed in collaboration with ABC News.

The study was supported by the National Heart, Lung, and Blood Institute and the National Institute on Aging.

One author has a patent pending on an allele as a marker of cardiovascular disease and stress, and is a founder and major stockholder in Williams LifeSkills.

Editorialist Gramling is funded by the National Palliative Care Research Center and the Greenwall Foundation.